RETURN TO:
The Surveyor-General
Environment and Sustainable Development
GPO Box 1908
CANBERRA ACT 2601

Request to have name removed from ACT Register			

I, (Name)

of, (Address)

wish to have my name removed from the ACT Register under Section 41 of the Surveyors Act 2007.

Signature:							Date:

NOTE:  If you wish to apply for Emeritus Surveyor status (this requires a minimum of 25 years service as a Registered Surveyor) apply in writing, providing a brief CV and/or personal history to the Surveyor-General at the above address.

Do you wish to remain on the Surveyor-General’s e-mail distribution list?		YES / NO

If YES, please supply your e-mail address: